Numerous clinical practice guidelines have been developed to improve the quality and lower the cost of health care. Unfortunately, these guidelines often fail to be used in clinical practice. The goal of this project is to improve compliance with guidelines by developing and evaluating a revolutionary approach for implementing clinical practice guidelines at the point of care. A clinical decision support system (CDSS) will be created that utilizes a World Wide Web-based guideline server that is directly accessible from within electronic medical record (EMR) systems. This CDSS will interactively lead a user through a selected guideline algorithm to generate patient-specific care recommendations during the visit. Initially, this project will involve the migration and expansion of an existing guideline CDSS from within an EMR system to a guideline server on the Web. The guideline server will be easily expandable to include new guidelines by storing guideline content and logic in a relational knowledge base which is incorporated into implementable programs using a generic code generator for guidelines. Linkages to relevant educational and instructional resources on the Web will be incorporated into the server. To enhance accessibility, a generic approach for directly accessing the guideline server from within EMR systems will be developed. A method for transferring critical data elements contained in the database of the EMR to the guideline server without compromising patient confidentiality will also be derived. The general applicability of the approaches used in this study will be demonstrated by implementing guidelines from diverse sources and by establishing access to the guideline server from within two technologically different EMR systems representing primary and secondary care settings. The impact of the guideline server on compliance with guideline recommendations, provider productivity and health care costs will be evaluated in a 12-month randomized controlled pilot study. The acceptability of the guideline server recommendations will be assessed through real time feedback when the guidelines are accessed and through user satisfaction surveys. The project team is experienced in the implementation of guidelines through computerization, in the development of code generators for creating programs from data stored in relational tables, and in programming Web-based applications. This team includes physicians, programmers, medical informaticians, a statistician and an expert in health policy and outcomes research. The team's ability to draw upon prior experience with the conceptual and technical issues related to this project will facilitate development of the guideline server. The long range objective of this work is to foster widespread utilization of clinical practice guidelines by overcoming implementation barriers.